Relapse Prevention in Patients With

Schizophrenia
B. van Meijel, M. van der Gaag, R.S. Kahn, and
M.H.F. Grypdonck
This article describes the development and content of a nursing intervention protocol for the recognition of the early signs of psychosis. Applying
this protocol, nurses can contribute to the prevention of psychotic relapse
in patients with schizophrenia or a related disorder. The background and
construction of the intervention protocol are described. The judgment of
experts in the care of patients with schizophrenia on the content and
applicability of the protocol is presented. Finally, the experience is summarized that has been acquired during the conduct of a number of case
studies of the application of the intervention protocol.
2003 Elsevier Inc. All rights reserved.

HE PREVENTION of psychotic relapse has

high priority in the treatment of patients with
schizophrenia. To achieve this goal, joint effort is
needed on the part of the patient, the members of
his or her social network, and professionals.
Nurses can contribute in several ways to this preventive objective. They have the opportunity to
offer the patient and the people in his or her environment education about schizophrenia and about
its implications for daily life; they can support the
patient in adequate use of medication; and, because
of their regular contact with the patient, they can
monitor his or her condition and take measures if
the condition requires it. This article concerns the
last possibility.
Research has shown that psychosis in most cases
arises gradually during a period from a few days to
weeks (Herz and Melville, 1980). Often, cognitive
perceptual changes and dysphoric symptoms first occur in the process of relapse, followed by prepsychotic or psychotic symptoms (Birchwood and
Spencer, 2001). These changes in feeling, thinking,
and acting that precede a psychosis are also called
early warning signs or prodromal symptoms. The
gradual development of psychosis offers opportunities for preventive intervention. When early warning
signs of psychosis occur and are reported (early recognition), appropriate measures can be taken that
promote the recovery of balance (early intervention).

The evaluation of the condition of the patient is

an activity that is often routinely done during the
contacts between the nurse and the patient. However, an inventory study in The Netherlands indicated that there is a need for further systematization of the knowledge about early recognition and
early intervention (van Mierlo, 1997).
This study attempts to respond to this need. We
describe the development of a nursing intervention
protocol oriented to the prevention of psychotic
relapse in patients with schizophrenia.
METHOD

In the development of complex nursing interventions, a careful procedure should be followed.

van Meijel et al. (2002c) have designed a model for
the development of evidence-based nursing interventions. The essence of this model is that a number of steps have to be followed for the intervention development that have the objective of
From the Department of Nursing Science, University
Medical Center Utrecht, Utrecht, The Netherlands.
Supported by a grant from Lundbeck BV.
Address reprint requests to B. van Meijel, RN, MSc,
PhD, Department of Nursing Science, University Medical Center, Utrecht, PO Box 85060, 3508 AB Utrecht, The
Netherlands. E-mail: B.K.G.vanMeijel@med.uu.nl
2003 Elsevier Inc. All rights reserved.
0883-9417/03/1703-0004$30.00/0
doi:10.1016/S0883-9417(03)00055-4

Archives of Psychiatric Nursing, Vol. XVII, No. 3 (June), 2003: pp 117-125

117

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providing the building blocks for the design of the

intervention. These building blocks can be assembled by means of (1) the literature, (2) analysis of
the problem for which the intervention is intended,
(3) research into the needs of patients and the
social system and the resulting demand for care,
and (4) research into already existing intervention
practices. The review of the literature is an obligatory component of the process of intervention
development. The use of the other research possibilities depends on the state of the knowledge and
the concrete research opportunities within the intervention area concerned.
The following two studies preceded the intervention development described in this article: (1) a
review of the literature (van Meijel et al., 2002d);
and (2) a qualitative study of present intervention
practices of early recognition and early intervention in The Netherlands (van Meijel et al., 2002a,
2002b). This study provides an understanding of
various methods and procedures that are presently
already applied. It also offers insight into the experiences and needs of patients, family members,
and care providers with these methods. The results
of these substudies constitute the basis for an initial
design of the intervention protocol. This design
was presented to eight experts in the area of
schizophrenia care: two psychiatric nurses, two
psychiatrists, two clinical psychologists, and two
family members of schizophrenic patients. They
studied the protocol and participated in a semistructured interview. Their judgments led to further
adaptation of the protocol.
The protocol was then tested in nursing practice.
Four nurses who work in a teaching hospital and
who have expert knowledge in the field of the care
of patients with schizophrenia received instructions on the background and application of the
protocol. Then, they applied the protocol with six
patients. The first author also applied the protocol
with two patients. Patient selection was done by
purposive sampling to have variation of the patient
characteristics regarding sex, age, illness duration,
treatment setting (clinic, day clinic, outpatient
treatment), severity of symptoms, and level of social functioning. The nurses kept a log in which
they noted their experiences, questions, and comments. The first author was available as a consultant for coaching the nurses while the protocol was
being applied.

VAN MEIJEL ET AL.

During the implementation of the protocol, the

nurses were interviewed at the following two
times: (1) halfway through the implementation of
the protocol, that is, after the inventorying of early
warning signs; and (2) after the protocol was completed in its entirety, ie, when all the relevant data
for the patient and the family were entered in a
symptom recognition plan. The results of the case
studies were used to improve the protocol.
First, we briefly discuss the theoretical model
that underlies the intervention. Second we present
the structure and the procedure of the protocol; and
third, we summarize the judgments of the experts
and describe a number of experiences from the
case studies.
THE THEORETICAL MODEL: THE
VULNERABILITYSTRESS MODEL

The vulnerabilitystress model is a tentative

model for treatment and research in the field of
schizophrenia and related disorders. The model
attempts to integrate the available state-of-the-art
knowledge in the field of schizophrenia into a
holistic perspective in which both biological and
psychosocial variables have a place (McGlashan
and Hoffman, 2000; Nuechterlein and Dawson,
1984; Nuechterlein et al., 1992; Nuechterlein et al.,
1994; Zubin and Spring, 1977; Zubin and Steinhauer, 1992).
The model (see Fig. 1) shows that the interaction
of (1) enduring personal vulnerability factors, (2)
personal protectors, (3) environmental protectors,
and (4) environmental potentiators and stressors
lead to intermediate internal states. Informationprocessing overload, tonic autonomic hyperactivitation, and deficient processing of social stimuli
characterize the condition of the patient. These
intermediate states can, when they exceed a certain
threshold of gravity, lead to the development of
prodromal symptoms. They can be the precursors of a psychotic relapse. The feedback loops
reflect the circularity of the model.
The model is excellently suited for the development of psychosocial interventions (Yank, Bentley, and Hargrove, 1993) because it makes the
variables visible on which these interventions can
be carried out. In the description of the intervention, we refer to this model.

RELAPSE PREVENTION IN PATIENTS WITH SCHIZOPHRENIA

Fig. 1

119

The vulnerability-stress-model. Reprinted with permission from Nuechterleing Dawson, Gitlin, et al. (1992).

THE INTERVENTION PROTOCOL: STRUCTURE

AND PROCEDURE

In this section, the main lines of the structure

and procedure of the protocol are described. The
review of the literature and the qualitative study
constitute the basis for the development of the
intervention. First a number of basic principles of
the protocol are described. Secondly, the various
phases in the intervention protocol are explained:
(1) the preparation phase, (2) the listing of early
warning signs, (3) the monitoring phase, and (4)
the action plan.
BASIC PRINCIPLES

For the application of the intervention, the following five basic principles have been formulated.
(1) The experiential world of the patient is the
starting point. The population of patients with
schizophrenia is very heterogeneous, as is the way
of experiencing schizophrenia. The assumption is
that starting with the actual life situation and the
subjective experience of the patient results in a
greater effectiveness of the intervention. This
means in practice that starting with the everyday
reality as it is experienced by the patient, with the
goals that the patient sets for himself or herself,
with the developmental phase in which the patient
is situated, and with the personal wording of the

patient. With this, justice is done to the uniqueness

of each individual and each life situation.
(2) The symptom recognition plan is tailormade. Precisely because of the unique character of
each situation, it is necessary to prepare an individual symptom recognition plan. To do justice to
this individual approach, one must carefully assess
the characteristics of the individual patient and of
his or her social network. With this, insight can be
obtained into factors that can promote or hinder
working with a symptom recognition plan in that
specific situation. With this understanding, an individualized intervention strategy can be established in function of the factors described (see The
Preparatory Phase).
(3) Working with a symptom recognition plan is,
if possible, a joint activity of the patient, the care
providers, and the members of the social network.
The literature and the qualitative preliminary study
show that the collaboration within this triad can
have considerable benefit for the preparation of the
symptom recognition plan, for early recognition of
the warning signs, as well as for early intervention.
(4) The symptom recognition plan continually
needs adjustment. In the course of time, new insights can arise about the early warning signs and
about the things that can be done within the framework of early intervention. The learning yield can

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VAN MEIJEL ET AL.

be increased for all parties by the constant translation of these new insights into the symptom
recognition plan. In this way, the chance becomes
greater that the symptom recognition plan will
receive continuous attention within nursing care.
(5) The care provider manifests positive appreciation. With early recognition and early intervention, the emphasis is on the increase of the control
over the course of the illness and over the consequences it has for the life of the patient and of the
people in his or her environment. This objective
will be achieved by trial and error. The motivation
to learn is increased when the care provider expresses appreciation for the efforts made by the
patient and others involved to develop a symptom
recognition plan and to apply it in the patients
own life situation.
THE PREPARATORY PHASE

The preparatory phase starts with the introduction of the theme working with a symptom recognition plan to the patient and the members of
his or her social network. The objective of this
introduction is engagement. First, one looks for the
relevance of early recognition and early intervention for the patient and the social network. What
positive effects can working with a symptom recognition plan have for the patient and for the
people in his or her environment? The effects to
which importance is attached vary widely among
patients. One patient will define the desired effects
in terms of anxiety reduction with regard to future
psychoses, another will be interested in the contribution it makes to rehabilitation goals (for example, living independently or being employed). By
the search for the personal meaning to the patient,
the intrinsic motivation is increased to make an
effort in early recognition and early intervention.
In addition, it is important to provide factual information. What does early recognition and early
intervention actually mean? What steps have to be
taken to draw up a symptom recognition plan?
What is expected from the patient and, perhaps,
from the members of the social network? How
much time will it take? For adequate information
transfer and motivating to cooperation, more than
one conversation might be needed.
The next step in the preparatory phase consists
of describing and analyzing a number of characteristics of the patient and the social network that
were found in the preliminary qualitative study to

influence effective working with a symptom recognition plan. They are divided into patient-related
and network-related characteristics. The patientrelated characteristics are the following:
1. Motivation: The patient, the care provider,
and the members of the social network are
asked for an assessment of the motivation of
the patient to make an active contribution to
working with a symptom recognition plan. If
the motivation is low, one looks for causes
and ways to influence them.
2. Insight into the illness: The level of insight is
a factor for the degree in which and the
manner in which the patient will collaborate
with the treatment. It also influences the capacity of the patient to reflect on his or her
own psychologic functioning. Insight is a
complex and multidimensional notion (Amador et al., 1993; David, 1990; McEvoy et al.,
1989a; McEvoy et al., 1989b). In the intervention protocol, these dimensions are translated into a number of subquestions that together lead to an assessment of the insight
into the illness of the patient. These subquestions concern the awareness of being psychiatrically ill, the interpretation of the psychotic experiences, the recognition of the
need for treatment, adherence to treatment,
and the recognition of the risk of psychotic
relapse.
3. Illness acceptance: The care provider is
asked to judge whether the patient has emotional reactions related to serious acceptance
problems regarding the illness, and its effects, that could hinder working on the symptom recognition plan at the time. If this is the
case, one may decide to postpone the preparation of the symptom recognition plan for
awhile and give priority in the assistance to
the acceptance problems.
4. The nature and severity of the symptoms: A
judgment is made of a number of positive,
negative, and cognitive symptoms that could
hinder the preparation of and working with
the symptom recognition plan.
5. Finally, a residual category is given of influential individual characteristics, such as personality characteristics of the patient, the
skill levels (for example, in coping and prob-

RELAPSE PREVENTION IN PATIENTS WITH SCHIZOPHRENIA

121

lem solving), the intelligence level, addiction

problems, and cultural background.

A psychotic episode that the patient can remember well is selected for discussion. At the reconstruction, one starts with the very first changes in
feeling, behavior, and thinking that were evident of
an impending relapse. Step by step, the nurse and
the patient try to describe the further course of the
relapse process as precisely as possible. The capacity and the needs of the patient determine the
depth to which this often-difficult period in his or
her life is discussed. Additional information from
members of the social network and from care providers can be valuable for completing the symptom
recognition plan, certainly when it concerns warning signs, which are less well perceived by the
patient or which he or she does not interpret as
warning signs. The intervention protocol has a
checklist of a number of common early warning
signs. This list can be useful in compiling the
inventory of early warning signs. All of the information together ultimately leads to an individual
profile of, at most, the five most important early
warning signs, a relapse signature, as Birchwood
(1992) calls it. When the persons involved cannot
agree on the ranking of the early warning signs, the
patient decides. Indeed, the presumption is that the
patient is the owner of the plan and that he or she
has to be able to concur with its content.
Then, the individual warning signs are worked
out further because one single indication of an
early warning sign is often insufficient to actually
be able to work with it. The distinction must be
made between the normal/stable situation (the
baseline) and the abnormalities in comparison to
this situation. For this, each early warning sign is
worked out on two or three levels. Level 1 gives
the normal or stable situation; level 2 gives a
description of the warning sign when it is present
in its light or moderate form; and level 3 gives the
situation when it is present to a serious degree. The
descriptions are prepared as concretely as possible
and in the words of the patient to make them easier
to recognize. The following example of the early
warning sign increasing suspicion can serve as
an illustration.

In the description of the social network, the

nurse is asked to examine the following three aspects:
1. The extent of the social network.
2. The readiness and the actual capabilities of
the members to participate in working with a
symptom recognition plan.
3. Any special characteristics of the network,
such as the level of expressed emotion.
The description and analysis of the patient-related and the network-related characteristics can
lead to the conclusion that a number of obstructing
factors are susceptible to change and others not (or
to a lesser degree). The care provider is encouraged
to formulate concrete steps for those factors that
are changeable in the relatively short term and so
can facilitate the preparation of a symptom recognition plan.
The last component of the preparatory phase
consists of the strategy determination. Here, the
following two questions are posed:
1. Is this the proper time to begin the preparation of the symptom recognition plan? Postponement can be considered when, for example, the level of positive symptoms is still too
high or when more attention must first be
paid to the acceptance problems.
2. To what extent is the patient capable of contributing himself or herself to the preparation
of and the working with a symptom recognition plan and to what extent is support of
other people required? The information from
this preparatory phase can be used to determine the need for support in divergent areas.
What is important is to keep the patient from
being over- or underquestioned, and to see to
it that optimal use is made of the capacities of
the patient and the supporting capabilities of
people in his or her surroundings.
LIST OF EARLY WARNING SIGNS

The object of this phase is the description of the

most important early warning signs. In one or more
discussions with the patient and, if possible, with
members of the social network, a reconstruction is
made of previous relapses.

Level 1: Normal/Stable
Regularly (almost daily) I think that people talk
and gossip about me. I can succeed in dismissing
these thoughts.

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VAN MEIJEL ET AL.

Level 2: Light/Moderate
I think constantly that others have got it in for
me. I regularly tell others that they should leave me
alone and that I dont want them gossiping about
me. I withdraw a lot, and I spend a lot of time alone
in my room.
Level 3: Serious
I have serious quarrels with others because I
think that they want to hurt me. I abuse and I
sometimes hit people.
THE MONITORING

At the monitoring of early warning signs, an

evaluation is made periodically of their presence or
absence. The presence indicates an increased risk
of a psychotic relapse, and specific actions might
be appropriate to keep the condition of the patient
from deteriorating. These actions are described in
the action plan (see the next section).
In the preparatory phase, the need for patient
support has been specified in the symptom recognition plan. The nurse can now use this knowledge
to instruct the patient and perhaps also the members of the social network regarding monitoring.
Concrete agreements are made about who contributes what to the monitoring.
Shortly after the completion of the symptom
recognition plan, monitoring should be done very
regularly, preferably weekly, under the guidance of
the nurse. In this way, the patient and the involved
members of the social network gradually can more
easily internalize the early warning signs. Afterwards, the frequency of the monitoring can vary
more in the course of time. The preliminary study
showed that weekly monitoring is not considered
desirable and necessary for many patients. Agreements must be made with the patient and the members of the social network involved about a feasible
intensity of the monitoring. Monitoring can be
intensified in specific periods, for example, in
times of increased stress, in periods in which medications are being changed, or in periods in which
early warning signs are already present.
The monitoring is done by scoring the level of
presence of early warning signs on a specially
designed score form.
THE ACTION PLAN

The objective of the action plan is the systematic

description of actions that can be taken by the

patient, members of the social network, and care

providers to prevent threatening psychosis. The
primary point of departure is that the patient and
the members of the social network always inform
the care provider when early warning signs occur.
Together, the gravity of the situation is assessed
and a decision is made about what must be done to
restore equilibrium. Thus, the patient has to have
someone to report to 24 hours a day to be able to
begin this consultation. The 24-hour availability is
the first point that is established in the action plan.
The components of the vulnerabilitystress model
are recognizable in the structure of the action plan.
With account being taken of the vulnerability of the
patient, ways are sought to avoid stress, to promote
coping, and to bring about protection from the environment. To clearly assign the responsibilities with
respect to the action plan, the actions are formulated
in succession for the patient, members of the social
network, and the care provider.
First, an inventory is drawn up with the patient
of the stressful situations that have to be avoided
when a relapse threatens. A retrospective evaluation is made of situations that yielded much stress
in the past. At the same time, one assesses which
stress-inducing situations are expected in the near
future. The distinction is made between external
stressors in the environment of the patient (for
example, a crowded place with many people and
much noise) and internal stressors (for example,
the patient is frequently placing major obligations
on himself or herself).
Then an inventory is drawn up of active coping
strategies that can support the patient in the recovery of equilibrium. These are also strategies that
were successful in the past or strategies that might
be expected to be successful in the future. One
might consider relaxing activities or the application of cognitive techniques (for example, selfreassurance). Medication adherence is a standard
aspect in the symptom recognition plan. Although
it cannot be expected that all of the patients will
simply comply with this, it can always be discussed by making it explicit in the plan. In this
way, it will be clear what the patient thinks about
it.
The third component of the action plan is making an inventory of activities that family members
or others directly involved can engage in and that
contribute to the protection and recovery of the
equilibrium of the patient. In the preparatory

RELAPSE PREVENTION IN PATIENTS WITH SCHIZOPHRENIA

123

phase, an evaluation is made of the capability of

the social network. The nurse can use this knowledge in testing the reality content of the proposed
activities. In other words, can one expect that the
proposed activities can actually be carried out and
lead to support and protection and thus to recovery
of equilibrium? In addition, what certainly should
not be done by people in the patients environment
because it increases the stress for the patient is
discussed with those involved. For example, one
may consider all kinds of concrete behavior that
lead to an increased level of expressed emotion,
with the most important characteristics being emotional over-involvement, critical statements, and
hostility because of the behavior of the patient.
Finally, the actions of the care provider are formulated. The following three types of actions are distinguished here: (1) actions that the care provider formulates from professional expertise (for example,
promoting medication adherence), (2) actions at the
request of the patient (for example, contacting the
employer to explain the condition of the patient), and
(3) actions at the request of family members and
other people involved (for example, more intensive
telephone contact with the parents of the patient to
keep them informed of the treatment policy and the
way in which they can contribute to this policy).
After description of all the relevant data in the
symptom recognition plan, it is determined in consultation with the patient who should receive a
copy of it. Generally, this is done in line with
previous agreements on the involvement of various
people in the compilation of the symptom recognition plan. The people who are involved only in a
late stage in the symptom recognition plan receive
information and instruction about the plan with
explicit attention to their specific contribution to
the preventive strategy.

Second, statements were made that were of a

more comprehensive nature. We summarize the
basic ideas here.
The experts were generally positive about the
amount of detail in the intervention protocol.The central place assigned to the perspective of the patient
and of the family was seen to be an important success
factor. The experts also appreciated the opportunities
the protocol offers for individualization. In their judgment, a good balance was found between structure
and individual customized work. The structure is
important to give the parties a grip when executing
the intervention, whereas the customized portion is
necessary to have the intervention be in line with the
individual situation of the patient and the members of
the social network as well as with the organizational
context within which care is provided.
Several experts stressed that the success of the
intervention depends largely on the level of competence of the nurse. The protocol is partially prescriptive, but also, for another part, requires adaptation of
the intervention strategy to understanding the present,
such as the understanding acquired in the preparatory
phase of the protocol. This working on the basis of
understanding places relatively high demands on the
ability of the nurse to carry out abstract clinical reasoning and clinical decision-making. It also makes
high demands on the communication skills of the
nurse to share considerations, if necessary and desirable, with the patient and the family to come to joint
decisions. In addition, the implementation of the protocol makes high demands on the organizational ability of the nurse. The intervention can lead to success
only if the nurse is the central person responsible for
the execution of the care. The imbedding of the
symptom recognition plan within the multidisciplinary collaboration and the synchronization with
the total treatment plan were cited as particularly
important.
Several experts offered critical comments on the
length of the intervention protocol. Their fear was
that the comprehensiveness in combination with
the extensive substructure of the various components would be at the cost of the readiness of
nurses to actually implement the protocol. In view
of the consistency with which the experts expressed this observation, a more concise version of
the intervention protocol was designed (the work
protocol). In organization and structure, this version corresponds with the original protocol, but
most of the explanatory information has been re-

THE JUDGMENT OF EXPERTS

The interviews with the six experts in schizophrenia care produced statements on two different
levels.
First, there were the statements on the various
details of the intervention protocol concerning formulations, additions, qualifications, and the like. They
were evaluated by the authors and have been incorporated in a subsequent version of the protocol if they
were considered able to improve the interventions.

124

VAN MEIJEL ET AL.

moved with a view to practical manageability. The

original protocol was used in the subsequent research (see the last section) primarily for educational purposes and as a reference work for the
protocol users.
CASE STUDIES

The nurses who participated in the case studies

also offered critical observations regarding the
practical manageability and the implementation of
the protocol. The need for a more concise version
of the protocol was stressed. At the same time, the
need for more intensive instruction was expressed,
in which the emphasis should be placed primarily
on practical examples and on the question of how
one should deal with an obstinate practice in which
the preparation of the symptom recognition plan
proceeds in a much less orderly manner than described in the intervention protocol. Particularly,
the reconstruction of earlier psychoses, the selection of the most characteristic warning signs, and
their effect in three levels (with sufficient internal
consistency and discriminatory power) were seen
to be difficult in a number of cases.
The experience of nurses was that implementation of the intervention protocol contributed a great
deal to the ordering of the information already
available. However, it also provided much new
information. For example, one of the nurses, by
implementing the protocol, realized the cognitive
limitations of the patient and in particular the
memory problems that made the execution of tasks
and compliance with agreements difficult. Another
nurse got to talking to the patient about the persisting symptoms and the way in which they had an
effect on everyday life. Again, another nurse
learned about a hitherto unexpressed intense anxiety on the part of the patient for a new psychosis,
an anxiety that was fed by statements of the attending physician.
Also important was that the experiential aspects
of earlier psychoses were discussed. The respondents noted that it must sometimes be very strange
for patients that such a major event as psychosis is
discussed so little with care providers. For a number of patients, experiences from previous psychotic episodes were discussed productively during the compilation of the symptom recognition
plan. However, there is also the risk of upset, as
appeared in one case. Old conflicts with the partner
were revived when previous psychotic episodes

were discussed, and strict structuring turned out to

be necessary to limit the upset for both the patient
and the partner.
In the execution of the case studies, a great deal
of empiric support was found for the individualization aspect. For one patient, a very detailed
symptom recognition plan could be drawn up
within 4 weeks because the patient manifested a
great deal of insight into the illness and readiness
to work to prevent future psychoses. She very
diligently and with great self-sufficiency did her
homework. For another patient, this process took
so long that it could not be completed within the
research period. The capacities of this patient were
significantly less. The preparations for transfer to
sheltered housing and an increase of psychotic
symptoms led to a delay of a number of months.
Another patient could not take in the information
on early recognition and early intervention because
she was preoccupied with obsessions that took all
her attention. This same patient also was afraid to
write things down on paper. She was afraid that she
would thus become too transparent. It required
much diplomacy to collect the necessary information without destroying the willingness of the patient to cooperate. Again another patient objected
to the word psychosis. She had spiritual experiences, and only with this wording could the
dialog proceed about preventive measures that
could contribute to her stability. With several patients, it was a matter of running the gauntlet
periodically not to overburden them and to maintain collaboration for the preparation of the symptom recognition plan. Also, the participation of
family or other members of the social network
needed individualized trajectories and using these
contributed to the success of the intervention.
In several cases, the symptom recognition plan
turned out ultimately to be a very good means of
communication for making explicit agreements
about the involvement of various people in care
delivery. From the perspective of the patient, this
meant the organization of social support and protection as well as the prevention of stress, for
example, in the form of a high level of expressed
emotion. From the perspective of the family, this
meant clarity regarding the question of the role
they could play in the care of the patient and also
clarity about when they could leave the care to
others.

RELAPSE PREVENTION IN PATIENTS WITH SCHIZOPHRENIA

CONCLUSION

This article describes the construction and preliminary testing of a nursing intervention protocol
directed to the prevention of psychotic relapse in
patients with schizophrenia. An attempt is made to
integrate the perspectives of the patient, family
members, and care providers within the procedure
of the protocol to achieve optimal collaboration in
the prevention of psychosis. The experiences of
patients and family members occupy an important
place within the proposed procedure. The expectation is that the readiness to use the protocol and the
effectiveness of the intervention increases with the
degree in which account is taken of these experiences. In the protocol, the rationale for the various
subinterventions is made explicit, which makes it
possible for the nurse to deviate from the protocol
when the concrete situation requires it. The case
studies made it clear that a different strategy was
used in each case to arrive at a symptom recognition plan, depending on divergent factors related to
the patient, social network, and care context. It also
became clear that the ideal circumstances are almost never present. The best possible strategy always has to be chosen within the existing possibilities and restrictions, which can vary
considerably over time. It requires a high level of
competence of the nurse to deal flexibly and creatively with these possibilities and restrictions.
Our experience is that working with protocols in
general is not particularly popular among care providers. Perhaps this is because they rapidly get the
impression that too much is prescribed and that the
opportunities for self-determination within the care
process are being curtailed. The case studies
showed that the emphasis on individualization of
the method was highly appreciated by the nurses.
We expect this to increase the readiness to integrate the proposed strategy of early recognition
and early intervention in the care that nurses offer
to patients with schizophrenia.
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